Mini-Review

Clinical Utility of Stewarts Method in Diagnosis and Management of Acid-Base Disorders

Asghar Rastegar
Nephrology Section, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
For the past 5 decades, a bicarbonate-based approach has been the dominant method used for the diagnosis and treatment of acid-base disorders. This approach, however, has been criticized by some as (1) qualitative and not quantitative in nature and (2) incapable of detecting important diagnoses. Stewart, using principals of electroneutrality and conservation of mass, developed a new approach to the diagnosis and management of these disorders. The proponents of Stewarts approach believe that it not only offers a mechanistic explanation for the disorders but also provides the tool to make a more accurate diagnosis. Although Stewarts approach has been largely ignored by nephrologists and renal physiologists, it is increasingly used by anesthesiologists and intensivists. This review discusses the clinical utility of Stewarts method compared with the traditional bicarbonate-based approach. Although Stewarts method proposes a different, however not new, approach, it does not improve our ability to diagnose more accurately or manage these disorders. Stewarts method also does not provide the tool to prognosticate any better than the traditional method. Clin J Am Soc Nephrol 4: 12671274, 2009. doi: 10.2215/CJN.01820309

eter Stewart, a biochemist at Brown University, published his seminal work on acid-base disorders in an article in 1978 and as a book in 1981 (1,2). Using fundamental biochemical and mathematical concepts, Stewart challenged the traditional bicarbonate-based method of diagnosing and treating acid-base disorders and proposed an approach based primarily on charge differences between strong cations and anions. This approach, however, did not attract much attention until the early 1990s, when it was simplified by several investigators to allow its use in clinical setting (3 6). This was followed by publication of a number of studies comparing the utility of the traditional and Stewarts approaches as a diagnostic and prognostic tool. It is interesting that until recently, Stewarts method has been largely ignored by nephrologists and renal physiologists, with only a rare article appearing in renal journals (7,8). This, however, should change as Stewarts method is increasingly used in clinical settings where nephrologists work side by side with intensivists and anesthesiologists who routinely use this method. Nephrologists should be familiar with Stewarts contribution to our understanding of acid-base disorders and its utility in clinical setting. A recent article discussed the mathematical and biochemical basis of Stewarts method in detail and challenged the basic concept that Stewart has created a new paradigm (8), a paradigm that is compared by some to Copernicuss discovering that Earth rotates around the sun and not vice versa (9)! In

addition, it challenges the claim that Stewarts approach provides a mechanistic explanation for acid-base disorders (8). This review will not deal with this issue, and readers who are interested in a more in-depth understanding of the biochemical and mathematical basis of Stewarts method are referred to this (8) as well as other reviews (3,4,6,7). This review focuses primarily on the clinical utility of Stewarts method, assessing its strengths and weaknesses as a diagnostic and prognostic tool. To do so, a brief history of key events leading to the development of the present approach to acid-base disturbances is in order. Table 1 summarizes the definition of key terms as well as abbreviations used in this article.

Historical Review of Approach to Clinical Acid-Base Disorders

The modern era of acid-base began in 1910 with Lapworths suggestion that hydrogen was the universal acid (10). This was extended by the work of Lowry in Cambridge (11) and Bronsted in Copenhagen (12), who defined an acid as a sub stance that is capable of donating hydrogen to and base as one capable of accepting hydrogen from a solution. This definition helped explain the natural avidity of acid and base and the role of weak acids and their salt in creation of buffer systems. Henderson (13) was first to recognize the unique role that bicarbonate-carbonic acid buffer system plays in stabilizing the acid-base equilibrium in body fluid. This led to the development of the Henderson-Hasselbalch formula:

Published online ahead of print. Publication date available at www.cjasn.org. Correspondence: Dr. Asghar Rastegar, Nephrology Section, Department of Medicine, Yale University School of Medicine, 1074 LMP, 333 Cedar St., New Haven, CT 06520-8056. Phone: 203-737-2078; Fax: 203-785-7030; E-mail: asghar.rastegar@yale.edu Copyright 2009 by the American Society of Nephrology

pH

pK

log

[HCO3 ] SXPCO2
ISSN: 1555-9041/4071267

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Table 1. Definitions and abbreviationsa AG ([Na ] [K ]) ([Cl ] [HCO3 ]) (normal range 14 to 16) or: AG [Na ] ([Cl ] [HCO3 ]) (normal range 8 to 12) AGc observed AG 2.5 ( normal albumin observed albumin ) observed AG 2.5 (4.4 observed albumin ), where albumin concentration is in g/dl A Primarily albumin and phosphate (in plasma) as well as hemoglobin (in whole blood) ATOT Total A and its weak acid ([A ] [HA]) Buffer base ([Na ] [K ] [Ca2 ] [Mg2 ]) ([Cl ]) HCO3 A BE or BD Amount of acid or alkali that must be added to 1 L of whole blood to restore pH to 7.40 at Pco2 of 40 SBE or SBD BE or BD corrected for hemoglobin and size of interstitial fluid compartment; this can be calculated by dividing BE by 3 or calculating BE using hemoglobin of 5 g/dl BEua BE corrected for changes in free water, chloride, albumin, and Pco2 (used as a surrogate for SIG) SID ([Na ] [K ] [Ca2 ] [Mg2 ]) ([Cl ]) [HCO3 ] [A ] SIDa ([Na ] [K ] [Ca2 ] [Mg2 ]) ([Cl ]) SIDe [HCO3 ] [A ] 12.2 Pco2/(10 pH) albumin in g/L (0.123 pH 0.631) PO4 in mmol/ L (0.309 pH 0.469). SIG SIDa SIDe
All units are in mEq/L, unless otherwise indicated. A , nonbicarbonate buffers; AG, anion gap; AGc, AG corrected for albumin; ATOT, total weak acids; BD, base deficit; BE, base excess; BEua, BE contributed by unmeasured anions; SBD, standard base deficit; SBE, standard base excess; SID, strong ion difference; SIDa, apparent strong ion difference; SIDe, effective strong ion difference; SIG, strong ion gap.
a

which became the foundation for future advances in this field. The clinical application of this formula was greatly advanced by Hasselbalchs invention of an electrode capable of measuring H ion concentration in body fluids (14). Beginning in the second decade of the 20th century, Van Slyke and Peters as well as other investigators helped to develop the bicarbonate-based approach to acid-base disorders (15). This approach was slightly modified by other investigators through the introduction of base excess (BE) and base deficit (BD) to quantify changes in bicarbonate concentration secondary to metabolic disorders (16,17). The use of BE and BD was criticized, however, because it represented measurements done on whole blood and did not accurately represent the whole-body behavior. This could lead to erroneous diagnosis, especially in patients with chronic respiratory acidosis, for whom the compensatory elevation in bicarbonate could be misdiagnosed as primary metabolic alkalosis (18). This criticism resulted in what was termed the great transatlantic debate between Copenhagen and Boston schools and the introduction of standard BE (SBE) and standard BD (SBD) to account for whole-body response to alterations in Pco2 (19). Interesting, whereas BD and BE are used clinically by intensivists and anesthesiologists, they are rarely used by nephrologists and renal physiologists. In this article, the term traditional approach is used to encompass both the original bicarbonate-base approach and its modification using BE and BD. The traditional approach is based on the centrality of H ion concentration and its dependence on the concentration of whole-body buffers as represented by bicarbonate and carbonic acid. Several investigators including Peters and Van Slyke, although accepting Henderson-Hasselbalchs formula, believed that a more complete description of the acid-base balance should include concentration of all of the anions and cations

(20). In the late 1940s, Singer and Hasting presented their acid-base nomogram and introduced the concept of buffer base (BB) as the difference between all of the cations (termed total base) and anions (termed total fixed acid) (16). On the basis of this terminology, cations such as sodium, potassium, and calcium are considered to be base and anions such as chloride and phosphate to be acid. This concept, discarded by basic chemists decades before, was challenged by several investigators and was finally abandoned by clinical chemists (21,22). During the next 2 decades, the traditional approach gained greater strength through the publication of many well-designed studies that defined the clinical and biochemical parameters that are critical to the diagnosis and management of acidbase disorders. These parameters became the foundations of our approach to clinical acid-base disorders for the past 4 decades (23).

Stewarts Approach to Acid-Base Disorders

As indicated, the traditional approach has been criticized as (1) descriptive rather than mechanistic in nature and (2) limited in scope and therefore unable to make complete diagnosis in patients with complex disorders. In contrast, proponents of Stewarts approach believe it to be mechanistic in nature and comprehensive in scope, able to detect important hidden disorders (6,24). The fundamental underpinning of Stewarts approach is the concept of independent and dependent variables in acid-base homeostasis. According to Stewart, Independent variables in any system are those which can be directly altered from outside the system without affecting each other and . . .dependent variables in a system can be thought of as internal to the system. Their values represent the systems reaction to the externally imposed values of the independent variables.

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Na

K Cl

Ca2 lactate

Mg2 other strong ions HCO3 A

Therefore,

SID

Na

K Cl

Ca2 lactate

Mg2 other strong ions HCO3 A .

Under normal conditions, concentration of lactate and other strong ions is very low and can be ignored. The formula could therefore be simplified to

SID
Figure 1. Relationship between SID, anion gap (AG), and bicarbonate in normal individuals.

Na

Ca2

Mg2 Cl HCO3 A

(1). Using principals of conservation of mass, electrical neutrality, and dissociation constant of partially dissociated weak electrolytes, Stewart derived the following fourth-order polynomial formula for H concentration in a fluid compartment containing bicarbonate and CO2:

H H H

3 2

Ka SID Ka SID Ka K 1 S ATOT PCO2 Kw K1 S Ka PCO2 K3 K1 PCO2 Kw } S 0 1,2

where strong ion difference (SID) is the difference between strong cations and anions in solution:

SID therefore can be calculated as the difference between fully dissociated cations and anions or sum of bicarbonate and A where A represents total charges contributed by all nonbicarbonate buffers, primarily albumin, phosphate, and, in whole blood, hemoglobin (Figure 1). SID is therefore the same as buffer base concept introduced by Singer and Hasting more than 5 decades ago (16). When an abnormal anion is present, a gap will appear between SID calculated by the difference between strong ions (the so-called apparent SID) and calculated by the addition of bicarbonate and nonbicarbonate buffers (so called effective SID; Figure 2). This difference, named strong ion gap (SIG), is a marker for the presence of an abnormal anion (25). Anion gap (AG) is also calculated on the basis of the principal of electroneutrality as shown as follows:

SID

Na

Ca2

Mg2 Cl lactate other strong ions

total cations

total anions unmeasured cations

measured cations measured anions unmeasured anions 0.

and ATOT reflects the concentration of total weak acid in solution:

This can be rearranged as:

ATOT

HA

measured cations

measured anions unmeasured cations AG.

On the basis of Stewarts definition, H and bicarbonate are dependent variables whose concentrations are determined by the three independent variables, namely SID, Pco2, and ATOT. Although the mathematical basis of Stewarts formula has not been challenged, this alone does not prove causality, which must be proved through empirical observations (8). In Stewarts approach, similar to the traditional approach, respiratory disorders are those that are due to a primary alterations in Pco2. Metabolic disorders, however, are due to primary alterations in SID or ATOT and not bicarbonate. By the law of electroneutrality:

unmeasured anions

Na

K lactate

Ca2

Mg2

Cl HCO3 A 0.
Figure 2. Relationship between strong ion gap (SIG) and AG.

other strong anions

This formula can be rearranged as follows:

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In normal state, plasma unmeasured anions reflect charges contributed by the nonbicarbonate anions (A ), primarily albumin and phosphate. The unmeasured cations are primarily made up of calcium, magnesium, and, depending on the formula used, potassium. AG, the difference between the abnormal and normal (or baseline) AG, represents the amount of abnormal anion(s) present in plasma. SIG, as pointed out already, also represents the amount of abnormal anion(s) present in plasma and is expected to be mathematically equal to AG (Figure 2). Moviat et al. (26) in studying 50 consecutive patients with metabolic acidosis (defined as BD 5 mM) documented a tight correlation between SIG and AG corrected for albumin and lactate (r 0.9344; Figure 3). This relationship could have been even stronger if AG were calculated in a more precise manner by using actual baseline values for AG in each patient rather than the mean value of 12 (27). It should be clear from this discussion that specific components of Stewarts formulas, such as SID and SIG, are conceptually and mathematically closely related to specific components of traditional formulas such as bicarbonate, AG, and AG. To help the reader become familiar with the application of commonly used formulas, the appendix summarizes the basic data and pertinent calculations on a patient evaluated by both methods.

dent variables (Table 2) (29). Respiratory disorders, as in the traditional approach, are due to a change in Pco2, whereas metabolic disorders are due to alterations in either SID or ATOT. SID is decreased in metabolic acidosis and increased in metabolic alkalosis. By calculating SIG, one can further classify metabolic acidosis. In hyperchloremic metabolic acidosis, both effective and apparent SID decrease equally, as the increase in chloride is counterbalanced by an equal decrease in the bicarbonate concentration. SIG therefore remains at or near 0. In AG metabolic acidosis, apparent SID does not change (as chloride concentration is unchanged), but effective SID decreases (as a result of a decrease in bicarbonate concentration) and SIG therefore becomes positive (29). One major departure from the traditional approach is classification of acid-base disorders as a result of alteration in ATOT. ATOT, representing all nonbicarbonate buffers pairs (HA A ), is made up of charges contributed primarily by serum proteins (mainly albumin) with phosphate and other buffers playing a minor role. On the basis of this classification, an increase in serum protein would result in metabolic acidosis and a decrease, metabolic alkalosis (see next section) (29,30).

Clinical Utility of Stewarts Approach in Diagnosing AcidBase Disorders

In addition to proposed disorders as a result of alterations in ATOT, the major practical difference between Stewarts and the traditional approach is the use of SID and SIG instead of bicarbonate and AG in the diagnosis of metabolic disorders. As pointed out already, these four variables all are interrelated, but the question remains: Does Stewarts method uncover disorders that are not diagnosed by the use of the traditional method? In a study of 152 intensive care unit (ICU) patients, 96% of whom had severe hypoalbuminemia (serum albumin concentration below the mean by 3 SD), Stewarts method uncovered underlying metabolic acidosis in 20 patients with normal BE and 22 patients with normal bicarbonate (29). The authors believe that the normal BE or bicarbonate was due to the presence of a counterbalancing hypoalbuminemic alkalosis. It is important to note, however, that in these patients, use of AG corrected for hypoalbuminemia also leads to the correct diagnosis of mixed metabolic acidosis and alkalosis (29). In a prospective observational study of 935 ICU patients, Stewarts method detected metabolic disorders in 131 (14%) patients with normal bicarbonate and BE, whereas the traditional method made a similar diagnosis in 108 (13%) patients. Stewarts method, however, failed to make an important acid-base diagnosis in 27 (3%) patients compared with the traditional method using corrected AG (31). In another study, 2152 complete sets of laboratory tests in 427 trauma patients were analyzed by the two methods. There was 28% disagreement between the two methods when corrected AG was not used (32). This is similar to the finding in another report in a pediatric population, in which base excess as a result of unmeasured anion was used as a surrogate for SIG (33). In summary, if corrected AG is used, then the traditional method performs at

Clinical Application of Stewarts approach

Classification of Acid-Base Disorders
One important goal of any method used to analyze acidbase disorders is to develop a clinically useful classification. The traditional approach, using a robust body of empirical observations, has developed a classification that contains six primary disorders: Metabolic acidosis, metabolic alkalosis, acute and chronic respiratory acidosis, and acute and chronic respiratory alkalosis. Metabolic acidosis can further be classified as anion gap or hyperchloremic acidosis. In addition, by using compensatory formulas as well as AG, the traditional approach is capable of diagnosing complex acid-base disorders (28). In Stewarts approach, classification of acidbase disorders is based on changes in the three indepen-

Figure 3. Relationship between AG and SIG. AG was corrected for albumin and lactate. SIG was also calculated correcting apparent SID for lactate. Reprinted from reference (26), with permission.

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Table 2. Classification of primary acid-base disturbancesa

Parameter Acidosis Alkalosis

Respiratory Nonrespiratory (metabolic) abnormal SID water excess/deficit imbalance of strong anions chloride excess/ deficit unidentified anion excess nonvolatile weak acids serum albumin inorganic phosphate

1Pco2 2SID, 2 Na 2SID, 1 Cl 2SID, 1 XA 1 Alb 1 Pi

2Pco2 1SID, 1 Na 1SID, 2 Cl

2 Alb 2 Pi

a For further discussion, refer to text and to reference (29). Alb , albumin concentration; Pi , inorganic phosphate concentration; XA, concentration of unidentified strong anion.

least as well as Stewarts approach in uncovering a hidden metabolic disorder. The role of hypoalbuminemia in the development of acidbase disorders deserves a comment. One report presents eight ICU patients with near-normal renal function and elevated serum bicarbonate concentration (mean 31.3 1.6 mM) but normal concentration of sodium, chloride, and appropriately low AG. Although other causes of metabolic alkalosis were not ruled out, it was assumed that this disorder was due to a decrease in total weak acid secondary to hypoalbuminemia (33). In contrast, in another study, among 935 ICU patients, only one patient was thought to have hypoalbuminemic alkalosis (31). In an in vitro experiment, a decrease in serum albumin from 4.7 to 2.8 g%, while maintaining constant Pco2, resulted in an increase in serum bicarbonate from 23.9 to 29.6 mM, whereas an increase in serum albumin to 6.6 resulted in a drop in serum bicarbonate to 19.2 mM (34). This study has been criticized for the use of whole blood rather than plasma and addition of diluting fluid with high bicarbonate content. In addition, the observed changes could be explained by the alteration in ionic strength resulting in a change in Gibbs-Donnan equilibrium and solubility as well as dissociation constant of CO2 (8). This in vitro observation is also not supported by the clinical observation that patients with nephrotic syndrome and similar degree of hypoalbuminemia have normal serum bicarbonate concentration (35).

these studies include very different patient populations, study designs, and statistical methods and are therefore difficult to compare or combine. In addition, because most variables of interest are interconnected, these studies are able to use only univariate and not multivariate analysis. Despite these limitations, certain general conclusions can be derived: 1. Clinical assessment such as APACHE II, injury severity index (ISI), and pediatric index mortality (PIM) are as powerful as the laboratory assessments in predicting clinical outcomes (32,36,39), 2. Correction of AG for albumin significantly increases its predictive power (38,41,42), 3. Correction of AG for albumin and SIG, on average, performed equally well in predicting mortality (32,39,40), 4. In two studies, both in trauma patients, receiver operator characteristic curve for SIG and AG achieved clinically useful levels (38,40). In other studies, reported receiver operator characteristic were too low to be of clinical use. 5. In no study was SIG compared with AG. 6. No studies compared the utility of Stewarts method with traditional method in diagnosing and/or managing respiratory disorders. In general, these types of studies using either the traditional or Stewarts approach, although interesting, are of questionable clinical utility in treating these severely ill and complex patients. The outcome in such patients will depend on multiple independent clinical and laboratory variables, which may or may not include acid-base parameters. We should also recognize the limitation of standard arterial blood gas analysis in informing us about buffering by the bicarbonate system at the tissue level. As pointed out by Gowrishankar et al. (42), this limitation is partly due to the fact that arterial Pco2, although setting the lower limit for capillary Pco2, does not accurately reflect the tissue buffering by bicarbonate system, which is better reflected by venous Pco2.

Prognostic Value of Stewarts Method Compared with the Traditional Method

The main goal of any proposed acid-base approach is to help clinicians make accurate diagnostic and therapeutic decisions. In this respect, as discussed, Stewarts method has not been shown to be superior to the traditional method. Many studies, however, have attempted to evaluate the ability of specific components of formulas used in either Stewarts or the traditional method in predicting meaningful clinical outcomes such as mortality (32,33,36 40). These studies, all performed on patients who were admitted to the ICU, are summarized in Table 3. As this summary shows,

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Table 3. Summary of studies comparing the prognostic power of the traditional and Stewarts approacha
Patient Population Clinical and Laboratory Measurements End Point(s) Results Comments

Author/Year (ref)

Study Design

BE, AG, BEua,b Lactate In-hospital mortality BEua (ROC 0.79) performed better than AG (0.64), and lactate level (0.63), BE (0.53)

BEua is used instead of SIG AGc not reported

Balasubramany Retrospective pediatric n 255 patients et al. (33), ICU with 1999 simultaneous measurements of acid-base parameters Rocktaeschel et Retrospective adult n 300 patients al. (36), 2003 ICU with simultaneous measurements of acid-base parameters BE, AG, AGc, BEua,b lactate, APACHE II n

Clinical Journal of the American Society of Nephrology

Hatherill et al. (37), 2003 n

Kaplan and Kellum (38), 2004 n

Prospective observational pediatric ICU Retrospective observational surgical ICU

Martin et al. (32), 2005

Retrospective surgical ICU

Gunnerson et al. (39), 2008

Retrospective observational medical and surgical ICU

Kaplan et al. (40), 2008

Prospective surgical ICU

Lactate level and BE, BEua, AG good BEua used instead of in- hospital predictor of lactate 5 SIG mortality but not mortality ROC BEua 0.64, AGc 0.67, BD 0.59, and AG 0.66 APACHE II best predictor of mortality BE, AG, SIG, ICU mortality Only ROC for lactate (0.83) Overall mortality in 46 children with shock Lactate, PIM and PIM (0.71) are this cohort 35% significant 282 vascular BD, AG, SID, SIG, 28-d mortality pH, BD, lactate, AG, SID, Single measurement in emergency trauma patients ISI, lactate SIG predict survival; department; AGc SIG, AG with ROC 0.99 not reported In univariate, age and 2152, laboratory BD, AG, AGc, SIDa, Lactate level and AGc and SIG best ISI and most acidtests in 427 SIDe, SIG, BEua, mortality predicted lactate level base parameters trauma patients ISI ROC for AGc 0.68 and predictor of BEua 0.70 best predicted mortality mortality AGc for albumin as SID, SIG, lactate, In hospital In logistic regression 851 suspected BE, AGc, age mortality analysis, lactate and SIG well as lactate lactic acidosis; as well as age and other tests done serum phosphate within 4 h predicted mortality; good correlation between SIG and AGc 78 consecutive SBE, AG, AGc, SIG, 28-d mortality ROC for SIG 0.959 greater 28-d mortality 33% patients with lactate than for AGc of 0.86 major trauma

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ICU, intensive care unit; ISI, injury severity score; PIM, pediatric index mortality; ROC, receiver operator characteristic curve. BEua is base excess corrected for water content as well as chloride, albumin, and Pco2 and reflects changes in BE as a result of presence of abnormal anion. This correlates closely with SIG. For details of the calculation, please refer to reference (33).

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Conclusions
Stewart, by creating an alternative view of acid-base universe and developing its own vocabulary and formulas, has challenged the traditional approach. This has led to the development of a new classification of acid-base disorders. This approach, however, is not a paradigm shift, as claimed by its proponents, but a variation on the widely known and controversial model using ionic charge differences to analyze acidbase disorders. In addition, the key components of the Stewarts formulas are closely related to the key components of the traditional formulas. Clinically, the traditional approach is intuitive in nature and is supported by a large body of robust empirical observations. The traditional approach should be abandoned only if proponents of Stewarts approach could provide clear empirical observations supporting its superiority as a clinical tool in diagnosing and treating patients with acidbase disorders. 3.

4.

5. 6.

7. 8.

Disclosures
None.

9.

10.

Appendix. Data from a patient who developed urosepsis resulting in lactic acidosis and acute kidney injurya
Parameter 1 2

11. 12.

Na K Cl HCO3 Ca P (mmol/L) Mg Albumin (g/dl) Lactate pH Pco2 (mmHg) AG AGc AG SIDa SIDe SIG

136 4.5 106 24 3.3 1.0 1.6 4.4 1.0 7.40 40 6 6 0 39 38 1

136 4.5 108 15 3.3 2.0 1.6 2.0 6.0 7.33 30 13 19 13 37 24 13

13. 14.

15.

16.

17. 18.

a Column 1 represents the baseline data, and column 2 represents data obtained on admission to the ICU with fever and hypotension. The formulas used in calculating AG, AGc, SIDa, SIDe, and SIG are shown in Table 1. AG is calculated as Na (Cl HCO3). Note the effect of hypoalbuminemia on AG and AG as well as the relationship between AG and SIG. All values are in mEq/L except as indicated.

19. 20. 21. 22. 23.

References
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